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Rio de Ki – Somatic Naturotherapy

Somatic Therapy

Intake Form

Welcome. Fill this in before our first session — it helps me understand your background so we can make the most of our time together.

About You

Your Name(Required)
Preferred pronouns(Required)
Relationship Status
Select any that apply.
Do you need an insurance receipt?(Required)
Verify with your provider that they cover Naturotherapists covered with the ACNN (Academy of Naturopaths and Naturotherapists of Canada).
Your Address (If you require an insurance receipt)

Session Focus

Which Areas Would You Like to Focus On?

How You're Feeling

Do you experience any of the following of a regular basis?
Sleep patterns
Select all that apply.
Stress Levels(Required)
Please rate the pace of your life 1 - 5(Required)

Mental Health & Support

Mental Health — How balanced do you feel?
Are you currently working with a licensed mental health professional?(Required)
e.g. therapist, psychologist, psychiatrist
Are you currently experiencing any significant emotional or psychological distress?
If yes, it may be beneficial to first consult with a licensed mental health provider. Need support right now? Call 1 866 APPELLE (1 866 277-3553) or text 535353, 24/7.

Goals & Boundaries

Is there any particular issue or area of your life you wish to focus on during our work together?
Anything you feel comfortable sharing now - we will explore deeper in person.
Areas of sensitivity or parts of your body where you prefer no physical contact ?
Including injuries, chronic conditions, medications

Packages

Packages are based on 60-min sessions. 90-min sessions available as standalone — ideal for deeper, focused work.
Somatic Reset

One Last Thing

Consent & Signature

Signature(Required)
By signing this form I consent to a Naturotherapy session using Somatic and Bioenergetic modalities.